Detection of Monkeypox Virus in Anorectal Swabs From Asymptomatic Men Who Have Sex With Men in a Sexually Transmitted Infection Screening Program in Paris, France
Authors: Valentine Marie Ferré, Antoine Bachelard, Meryem Zaidi, Laurence Armand-Lefevre, Diane Descamps, Charlotte Charpentier, Jade Ghosn
Journal: Annals of Internal Medicine (2022)

Letters16 August 2022Detection of Monkeypox Virus in Anorectal Swabs From Asymptomatic Men Who Have Sex With Men in a Sexually Transmitted Infection Screening Program in Paris, FranceFREEValentine Marie Ferré, PharmD, Antoine Bachelard, MD, Meryem Zaidi, BSc, Laurence Armand-Lefevre, PharmD, PhD, Diane Descamps, MD, PhD, Charlotte Charpentier, PharmD, PhD, and Jade Ghosn, MD, PhDValentine Marie Ferré, PharmDService de Virologie, Université Paris Cité, INSERM, IAME, UMR 1137, AP-HP.Nord, Hôpital Bichat-Claude Bernard, Paris, France (V.M.F., M.Z., D.D., C.C.), Antoine Bachelard, MDService de Maladies Infectieuses et Tropicales, Université Paris Cité, INSERM, IAME, UMR 1137, AP-HP.Nord, Hôpital Bichat-Claude Bernard, Paris, France (A.B., J.G.), Meryem Zaidi, BScService de Virologie, Université Paris Cité, INSERM, IAME, UMR 1137, AP-HP.Nord, Hôpital Bichat-Claude Bernard, Paris, France (V.M.F., M.Z., D.D., C.C.), Laurence Armand-Lefevre, PharmD, PhDService de Bactériologie, Université Paris Cité, INSERM, IAME, UMR 1137, AP-HP.Nord, Hôpital Bichat-Claude Bernard, Paris, France (L.A.), Diane Descamps, MD, PhDService de Virologie, Université Paris Cité, INSERM, IAME, UMR 1137, AP-HP.Nord, Hôpital Bichat-Claude Bernard, Paris, France (V.M.F., M.Z., D.D., C.C.), Charlotte Charpentier, PharmD, PhDService de Virologie, Université Paris Cité, INSERM, IAME, UMR 1137, AP-HP.Nord, Hôpital Bichat-Claude Bernard, Paris, France (V.M.F., M.Z., D.D., C.C.), and Jade Ghosn, MD, PhDService de Maladies Infectieuses et Tropicales, Université Paris Cité, INSERM, IAME, UMR 1137, AP-HP.Nord, Hôpital Bichat-Claude Bernard, Paris, France (A.B., J.G.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M22-2183 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Background: A monkeypox virus (MPXV) outbreak emerged in May 2022, affecting mostly men who have sex with men (MSM). Although most infections were characterized by cutaneous lesions, a recent report described 3 asymptomatic men with no cutaneous lesions but with positive results on anorectal MPXV polymerase chain reaction (PCR) testing (1). Determining whether MPXV infection can be asymptomatic may better inform epidemic management.Objective: To assess the presence of MPXV in anorectal samples among asymptomatic MSM routinely tested for bacterial sexually transmitted infections (2).Methods and Findings: We retrospectively performed testing for MPXV on all anorectal swabs that were collected in our center as part of a screening program for Neisseria gonorrhoeae and Chlamydia trachomatis. Per French guidelines, this screening is performed every 3 months among MSM with multiple sexual partners who are either taking HIV preexposure prophylaxis (PrEP) or living with HIV and receiving antiretroviral treatment (2). Patients could have urine samples and anal swabs collected at our clinic or a private laboratory. After the first case of MPXV infection was identified in France on 19 May 2022, screening was halted in patients who had lesions suspicious for MPXV (3). We report on asymptomatic MSM who tested negative for N gonorrhoeae and C trachomatis on MPXV anal swabs collected at the Infectious Disease Department and the Sexual Health Clinic of Bichat-Claude Bernard Hospital in Paris, France, from 5 June to 11 July 2022. All participants attended a clinical visit on the day of sampling as part of routine PrEP or HIV treatment follow-up. Participants gave written informed consent to have their data recorded in Nadis (www.dataids.org; Fedialis Medica, CNIL number 1171457 [24 May 2006]), an electronic medical record designed for follow-up of persons living with HIV or receiving HIV PrEP and use of their data for research. The local review board did not require specific consent to use remnant routine biological samples in the setting of the MPXV epidemic.After heat inactivation (12 minutes at 70 °C), nucleic acids were extracted using a STARMag 96 X 4 Universal Cartridge Kit (Seegene) on the MICROLAB NIMBUS system (Seegene). MPXV-specific PCR was performed using a previously published protocol (4).During the study period, 706 MSM visited our clinic, 383 had symptoms suggestive of MPXV infection (40% had anal lesions), and MPXV infection was confirmed in 271 of those with symptoms (Table). Screening for C trachomatis and N gonorrhoeae infection was not performed when MPXV infection was suspected because of laboratory biosafety restrictions (5). Of the 706 MSM, 323 had no MPXV symptoms, and 213 had anal swabs collected and were negative for C trachomatis and N gonorrhoeae (Table). Among these 213 MSM, the median age was 38 years (IQR, 29 to 48 years), and 110 (52%) were living with HIV and receiving antiretroviral therapy, with a median of 9 years (IQR, 4 to 18 years) since diagnosis. Among those with HIV, 78% had undetectable viral load (median viral load was 74 copies/mL [IQR, 37 to 2270 copies/mL] in the others), and the median last CD4 T-cell count was 0.766 × 109 cells/L (IQR, 0.560 to 1.001 × 109 cells/L).Table. Screening for Sexually Transmitted Infections and MPXV Infection in 706 MSM Visiting the Sexual Health Clinic Between 5 June and 11 July 2022MPXV PCR was successfully performed on 200 of 213 anal swabs and was positive in 13 (6.5%). Of those testing positive, 8 were living with HIV; all had undetectable HIV-1 viral load, and all had a CD4 T-cell count above 0.500 × 109 cells/L, except 1 who had a CD4 T-cell count of 0.123 × 109 cells/L. We contacted all 13 MPXV-positive participants who were initially asymptomatic to assess symptom status and advised them to limit sexual activity for 21 days after the test date and to notify their recent sexual partners. None reported symptoms suggestive of MPXV infection, but 2 subsequently presented to our clinic with symptoms. One had a cycle threshold (Ct) value of 20.7 on PCR of the sample taken during the asymptomatic stage and a Ct value of 33.0 seven days later, when he presented with anal rash. The other presented with pharyngitis and fever but no anal symptoms; PCR on the anal swab taken during the asymptomatic phase showed a Ct value of 38.2, and PCR on a pharyngeal swab 9 days later showed a Ct value of 24.Of the 187 asymptomatic participants who tested negative for MPXV, 3 presented to our clinic more than 3 weeks after the initial MPXV-negative anal swab with symptoms suggestive of MPXV infection and tested positive.Discussion: This report documents positive MPXV PCR results from anal samples in asymptomatic MSM. Whether this indicates viral shedding that can lead to transmission is unknown. If so, the practice of ring postexposure vaccination around symptomatic persons with probable or confirmed MPXV infection may not be sufficient to contain spread. Recent French recommendations have advised vaccination for all MSM with multiple partners (5).References1. De Baetselier I, Van Dijck C, Kenyon C, et al. Asymptomatic monkeypox virus infections among male sexual health clinic attendees in Belgium. Preprints with The Lancet. Preprint posted online 21 June 2022. doi:10.2139/ssrn.4142074 CrossrefGoogle Scholar2. Conseil National du Sida et des Hépatites Virales; Agence Autonome de l'Inserm. Medical Care for People Living with HIV: Recommendations from Expert Group. April 2018. Accessed at https://cns.sante.fr/wp-content/uploads/2018/05/experts-vih_suivi.pdf on 13 July 2022. Google Scholar3. Société Française de Microbiologie. Gestion des prélèvements biologiques d'un patient suspect ou confirmé d'infection par le Monkeypox virus (MPXV). Version 1_MAJ. 11 June 2022. Google Scholar4. Li Y, Zhao H, Wilkins K, et al. Real-time PCR assays for the specific detection of monkeypox virus West African and Congo Basin strain DNA. J Virol Methods. 2010;169:223-7. [PMID: 20643162] doi:10.1016/j.jviromet.2010.07.012 CrossrefMedlineGoogle Scholar5. General directorate of health. Monkeypox – evolution de la conduite a tenir, elargissement de la vaccination et mise a disposition du tecovirimat. 8 July 2022. Accessed at https://solidarites-sante.gouv.fr/IMG/pdf/_corruss_dgs-urgent_n2022_65_avis_has.pdf on 13 July 2022. Google Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: Service de Virologie, Université Paris Cité, INSERM, IAME, UMR 1137, AP-HP.Nord, Hôpital Bichat-Claude Bernard, Paris, France (V.M.F., M.Z., D.D., C.C.)Service de Maladies Infectieuses et Tropicales, Université Paris Cité, INSERM, IAME, UMR 1137, AP-HP.Nord, Hôpital Bichat-Claude Bernard, Paris, France (A.B., J.G.)Service de Bactériologie, Université Paris Cité, INSERM, IAME, UMR 1137, AP-HP.Nord, Hôpital Bichat-Claude Bernard, Paris, France (L.A.)* Professor Charpentier and Professor Ghosn contributed equally to this work.See Also: Editorial commentDisclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M22-2183.Reproducible Research Statement: Study protocol, statistical code, and data set: Not available.Corresponding Author: Charlotte Charpentier, PharmD, PhD, Hôpital Bichat-Claude Bernard, Laboratoire de Virologie, 46 Rue Henri Huchard, 75018 Paris, France; e-mail, charlotte.[email protected]fr.This article was published at Annals.org on 16 August 2022. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoAnnals of Internal Medicine16 Aug 2022Asymptomatic Infection? Another Reason to Consider Monkeypox a Disease of Public Health Concern Stuart N. Isaacs Metrics Cited ByAsymptomatic Infection? Another Reason to Consider Monkeypox a Disease of Public Health ConcernStuart N. Isaacs, MD LatestKeywordsChlamydia trachomatisHIVLesionsMale male sexual contactMonkeypoxPreexposure prophylaxisSexually transmitted diseasesSkin infections CopyrightCopyright © 2022 by American College of Physicians. All Rights Reserved.Loading ...